Avaliação do nível de conhecimento e prevalência de infecção por Toxoplasma gondii entre gestantes de Santa Catarina, Brasil

 

Anelise Cristina Kohler¹, João Victor Serenini², Karina Duarte Alves², Andréa do Livramento³, Tatiani Karini Rensi Botelho³

 

¹  Fundação Universidade Regional de Blumenau, Curso de Biomedicina, Blumenau, SC, Brasil.

²  Fundação Universidade Regional de Blumenau, Curso de Farmácia, Blumenau, SC, Brasil.

³  Fundação Universidade Regional de Blumenau, Departamento de Ciências Farmacêuticas, Blumenau, SC, Brasil.

 

Recebido em: 06/06/2021

Aprovado em 07/03/2022

DOI: 10.21877/2448-3877.202202151

 

INTRODUCTION

 

Infections caused by parasites represent an important worldwide health problem. Among them, we highlight those originated by protozoa such as Toxoplasma gondii (T. gondii), which, due to their high incidence, require preventive public health actions.⁽¹⁾ This obligate intracellular parasite is the etiologic agent of toxoplasmosis, a zoonosis of high infectivity.⁽²⁾

The main pathway of transmission of T. gondii to humans is through the consumption of raw or undercooked meat, especially pork and goat meat, which is contaminated with tissue cysts. Another form of transmission occurs through the ingestion of oocysts that are eliminated in the feces of the definitive hosts, especially cats, and that is capable of contaminating water, soil and food. In addition, the parasite can also be transmitted to the fetus via the transplacental route.⁽³⁾

In immunocompetent individuals and pregnant women, toxoplasmosis is self-limiting and benign. Usually, it appears as asymptomatic or with mild symptoms such as fever, headaches, epigastric and muscle pain.^(4,5,6) In fetuses and newborns, infection by T. gondii is severe, which can lead to serious complications.⁽⁷⁾

Congenital toxoplasmosis has high rates of infant morbidity and mortality in worldwide, with approximately 15% of intrauterine death from fetal infections. In addition, in 80% of cases of fetal affection, symptoms are late.⁽⁸⁾

In this context, prenatal care during pregnancy is extremely important for the early diagnosis and treatment of patients who come into contact with the protozoan, as well as, after birth, monitoring the newborn.⁽²⁾ By the fact that, when the diagnosis occurs prematurely there are chances that, with correct treatment, prevent or decrease fetal infection, substantially reducing the sequelae.⁽⁹⁾ In addition, it is important to emphasize the prevention actions of congenital toxoplasmosis, which can be accomplished via strategies related to the guidance for pregnant women on preventive behavior and the basics knowledge of transmission.⁽¹⁰⁾

Nevertheless, is necessary more seroprevalence data for T. gondii among pregnant women in Brazilian cities and states, in order to provide support for the implementation of public health actions pointing to clarify prevention strategies, risks, and way of transmission of toxoplasmosis in pregnancy.⁽²⁾ Therefore, the present study aimed to determine the prevalence of T. gondii infection in pregnant women attended at Basic Health Units (UBS) in Santa Catarina, as well as to evaluate knowledge about toxoplasmosis among the population studied.

 

MATERIALS AND METHODS

 

This article is a cross-sectional prevalence study. In this study, was evaluated the total of 109 pregnant women attended at UBS in the Santa Catarina cities of Brusque (from March to April 2018) and Blumenau (from January to May 2019).

Blumenau is located in the northern region of Santa Catarina. Its urban area is divided into 35 neighborhoods, including 2 districts, and its estimated population is 361,855 inhabitants.⁽¹¹⁾ The city has 74 UBS, of which two, located in the downtown of the city, were included in the survey.

Brusque, in turn, has a population of 137,689 habitants.⁽¹²⁾ The city is divided into 31 neighborhoods, in addition to the Chácara Edith Private Natural Heritage Reserve (RPPN).⁽¹³⁾ Of the 31 neighborhoods in the city, 23 of them have UBS. Herein, 10 of these UBS were evaluated, which correspond to 11 neighborhoods.

Through the collection of data obtained through the pregnant woman’s handbooks, the results of serological tests were analyzed for the detection of IgG and IgM anti-T. gondii. The pregnant women were considered seropositive, when the presence of IgG reagent accompanied or not by IgM reagent. Those patients who presented non-reactive results for IgG and IgM antibodies were classified as susceptible to infection.

In addition, a questionnaire was applied regarding the participants’ sociodemographic and socioeconomic characteristics. The variables surveyed were: age group, education level and monthly family income, as well as obstetric aspects and knowledge of pregnant women about toxoplasmosis.

The inclusion criteria of the research were: presence of pregnancy confirmed clinically or through exams; prenatal care performed at the UBS and signing the Free and Informed Consent Form.

 

ETHICS

 

This study was approved by the Human Research Ethics Committee of the Fundação Universidade Regional de Blumenau (FURB), protocol number 2.440.560 and 3.033.737.

 

RESULTS

 

Among the pregnant women analyzed, 47.7% (n = 52) were attended at UBS in the city of Blumenau, and 52.3% (n = 57) in the city of Brusque.

The range of age participants was 18 to 40 years old, and in Blumenau and Brusque, the prevalent age group was 20-25 years. Furthermore, the socioeconomic profile was similar among participants from both cities, with a majority family income ranging from 2 to 3 monthly minimum wages. As for education, it was observed that the rate of volunteers with undergraduate education was higher in Blumenau (Table 1).

Regarding the gestational period of the participants, among those from Blumenau, 28.8% (n = 15) were in the third trimester of pregnancy, 51.9% (n = 27) in the second trimester, and 19.2 % (n = 10) in the first trimester. Considering the city of Brusque, 57.6% (n = 33) of the volunteers were in the third trimester of pregnancy, 28.1% (n = 16) in the second trimester, and 14.0% (n = 8) in the first trimester.

In Blumenau, it was not possible to access the results of serological tests for the detection of anti-toxoplasma antibodies of 14 pregnant women’s handbook (26.9%). While in participants from Brusque, the results of these tests were analyzed in full. The serology data obtained from the pregnant woman’s handbooks are described in Table 2.

The prevalence of IgG anti-T. gondii with or without IgM among pregnant women was 53.7% (n = 51). The results obtained by the pregnant women’s handbook also revealed a seropositivity of 1.0% (n = 1) for IgG and IgM anti-T. gondii, concomitantly. However, 45.3% (n = 43) of the population analyzed was considered susceptible to infection by the protozoan, showing negativity for IgG and IgM antibodies (Table 2).

In the present study, a data survey of toxoplasmosis in pregnant women revealed that the majority of interviewees in the two cities does not have knowledge about the disease (Table 3).

 

 

Table 1

Sociodemographic and socioeconomic characteristics of pregnant women attended at UBS in Santa Catarina.

	Blumenau	Brusque	Total
Variable	n (%)	n (%)	n (%)
Age (years)
15-19	4 (7,7%)	6 (10,5%)	10 (9,2%)
20-25	25 (48,1%)	22 (38,6%)	47 (43,1%)
26-30	12 (23,1%)	15 (26,3%)	27 (24,8%)
31-35	5 (9,6%)	10 (17,5%)	15 (13,8%)
36-40	6 (11,5%)	4 (7,0%)	10 (9,2%)
Total	52 (100%)	57 (100%)	109 (100%)
Education
Illiterate	̶	1 (1,8%)	1 (0,9%)
Incomplete Elementary School	2 (3,8%)	8 (14,0%)	10 (9,2%)
Complete Elementary School	2 (3,8%)	10 (17,5%)	12 (11,0%)
Incomplete High School	5 (9,6%)	10 (17,5%)	15 (13,8%)
Complete High School	19 (36,5%)	21 (36,8%)	40 (36,7%)
Undergraduate	24 (46,2%)	7 (12,3%)	31 (28,4%)
Total	52 (100%)	57 (100%)	109 (100%)
Monthly family income
Up to 1 minimum wage	2 (3,8%)	17 (29,8%)	19 (17,4%)
2 to 3 minimum wages	33 (63,5%)	27 (47,4%)	60 (55,0%)
4 to 5 minimum wages	15 (28,8%)	10 (17,5%)	25 (22,9%)
Above 6 minimum wages	2 (3,8%)	2 (3,5%)	4 (3,7%)
Others	̶	1 (1,8%)	1 (0,9%)
Total	52 (100%)	57 (100%)	109 (100%)

 

 

Table 2

Frequency of IgM and IgG anti-Toxoplasma gondii antibodies in pregnant women attended at UBS in Santa Catarina.

	Blumenau	Brusque	Total
Antibodies	n (%)	n (%)	n (%)
IgG (+) IgM (-)	20 (52,6%)	30 (52,6%)	50 (52,6%)
IgG (+) IgM (+)	̶	1 (1,8%)	1 (1,0%)
IgG (-) IgM (+)	1 (2,6%)	̶	1 (1,0%)
IgG (-) IgM (-)	17 (44,7%)	26 (45,6%)	43 (45,3%)
Total	38 (100%)	57 (100%)	95 (100%)

 

 

Table 3

Knowledge of pregnant women attended at UBS in Santa Catarina about toxoplasmosis.

	Blumenau	Brusque	Total
Level of knowledge	n (%)	n (%)	n (%)
Unknown	8 (15,4%)	13 (22,8%)	21 (19,3%)
You’ve heard, but don’t know nothing about it	28 (53,8%)	28 (49,1%)	56 (51,4%)
Know something about	16 (30,8%)	16 (28,1%)	32 (29,4%)
Total	52 (100%)	57 (100%)	109 (100%)

 

 

 

DISCUSSION

 

The results of the serological tests presented here were similar to those of other studies carried out with pregnant women in the southern region of Brazil.^(14,15) However, the frequency of IgG anti-T. gondii antibody is lower compared to studies carried out in other regions of the Brazil, as 77.9% in Maranhão;⁽²⁾ 77.5% in Recife, Pernambuco⁽⁵⁾ and in Cuiabá, where the marker of contact with the parasite was evidenced in 70.7% of pregnant women attended by the Unified Health System.⁽¹⁶⁾

The prevalence of positive IgG and IgM antibodies variable in worldwide, including within the country itself.⁽¹⁷⁾ This variation may be related to diet behavior, hygiene, basic sanitation, geographic location, socioeconomic conditions and factors of each population.⁽¹⁵⁾ The seroprevalence data found in Brazil are high when compared to other countries: 10.3% in Japan;⁽¹⁸⁾ and 11.9% in England.⁽¹⁹⁾ In Mexico, the prevalence among pregnant women is considered low, varying between 6.1% and 8.2%. ⁽²⁰⁾

In this survey, only one pregnant woman (1.0%) was positive for IgG and IgM anti-T. gondii, simultaneously. However, due to the unavailability of the avidity of the IgG antibody data, it was not possible to determine if was an acute infection, since the presence of IgM class antibodies can be detected up to 18 months after the primary infection, called as residual antibodies.⁽²¹⁾

It is also worth pointing out the susceptibility index, IgG and IgM non-reactive, of the pregnant women here studied, which makes women vulnerable to T. gondii and, consequently, at greater risk of acquiring the infection during pregnancy. Thus, it is importante to emphasize the importance of implementing actions to prevent and control the infection, thereby reducing the number of congenital infections.

The risks of vertical transmission and the severity of the sequelae are directly related to the gestational period at which the infection occurs.⁽²²⁾ The consequences of congenital toxoplasmosis for the fetus are several, as abortion, intrauterine growth restriction, prematurity, low weight and other damages to the newborn, such as: chorioretinitis, strabismus, jaundice, hepatomegaly, brain calcifications, hydrocephalus and developmental delay.^(7,23)

Considering that maternal-fetal transmission can be avoided with early diagnosis and treatment, the rate of absence of information on serology for T. gondii reported here represents a negative indicator. In addition, the fact that the minority of participants was in the first trimester of pregnancy may be related to the delay in starting prenatal care. In this context, examinations are performed late, potentially resulting in a high incidence of congenital toxoplasmosis.

In Brazil, a serological test at the first prenatal visit is part of the routine of pregnant women care. However, the main problem is a non-repetition of serological tests during pregnancy. In addition, part of the pregnant women does not receive any prenatal care or receive care in advanced period of pregnancy. In this case, even if the tests detect specific maternal antibodies, it will not be possible to identify whether the infection was acquired before or during pregnancy.

According to the data here analyzed, it was observed that the majority of pregnant women in the two cities in Santa Catarina are not aware of toxoplasmosis. This is not consistent with the fact that most of the participants in Blumenau has undergraduate. The approach to information by pregnant women is a fundamental part of the disease prevention, especially among those who are classified as susceptible to infection. In this way, health professionals develop an essential role in the health information and education, as they are in direct contact with pregnant women and the community in general. Therefore, it is essential that they are updated and attentive to the demands of the community.⁽²⁴⁾

 

CONCLUSION

 

In conclusion, the results of this study demonstrated the essential to promote public health policies to elucidate about T. gondii infection among pregnant women, as well as the prevention and control of toxoplasmosis in pregnancy. These actions are an important tool for reducing fetal infection and reducing the morbidity and mortality rates associated with congenital toxoplasmosis.

 

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Correspondência

Andréa do Livramento

Departamento de Ciências Farmacêuticas
Universidade Regional de Blumenau – FURB
Campus III – Rua São Paulo, Itoupava Seca
CEP 89030-000 – Blumenau – SC Brasil

E-mail: [email protected]